July 1, Greetings,

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1 July 1, 2008 Greetings, Thank you for your interest in membership with Congregation Adat Yeshurun. Attached please find the necessary membership forms which must be completed and returned to our office. It is important that you complete every form in the package. The forms are: 1. Membership Information/Yahrzeit Information/Children s Information 2. Wish to Participate Form 3. Biography and Photo Page 4. Dues Schedule for the current membership year 5. Credit Card Authorization Form Please note the dates you provide must be complete with day, month, and year. You may provide either a Hebrew or English date, but we must have all three pieces of information to ensure accurate and timely Yahrzeit notices are sent to you. Hebrew names should be as complete as possible (i.e. Yaacov ben Avraham or Yael bat Dovid) and written in English. Please return the completed forms as soon as possible to the office via mail or fax. If you have received this form via you have the option of completing the form within the attachment and ing back. Feel free to contact me if you have any questions or need assistance completing the forms. Kindest regards, Annette Olson Executive Administrator Congregation Adat Yeshurun Enc.

2 Congregation Adat Yeshurun Communication Form The Shul office staff is continuing the implementation of wide spread use of electronic communication in the form of s with attachments (i.e. Word or PDF files). Information is also available via our website In order to download the PDF files you will need Adobe Reader, which is available for free at Click on the Get Adobe Reader button or go directly to and follow the instructions. Please complete the information below and check the addresses the office staff should use to Shul information to you. Address: Home Telephone: Address Family: Address Member 1: Address Member 2: If you do not have access to a computer or you may request to receive Shul communications via postal mail. Please help us to manage our costs only request communications via postal mail if you cannot receive them electronically. Please check the box below if you need to receive communications via postal mail and be sure to complete the Address section above. Please send Shul communications via postal mail

3 Individual Member Information Please complete the membership information below with your and your spouse s (if applicable) information. Member 1 Information: Member 2 Information: Title: Title: Hebrew Hebrew Member 1 Member 2 Business Phone: Business Phone: Mobile Phone: Mobile Phone: Pager: Pager: Father s Hebrew Father s Hebrew Mother s Hebrew Mother s Hebrew Birthday: Birthday:

4 Yahrzeit Information Please provide the Yahrzeit information you would like on file, listing each person separately. Please remember your date information MUST BE COMPLETE in order to ensure accurate and timely receipt of Yahrzeit Notices. Please provide all three of the following: month, day and year of death. You may provide either a Hebrew date of death or English date of death. Member 1 Yahrzeit Information: Member 2 Yahrzeit Information: Relationship of Deceased to Member 1 Relationship of Deceased to Member 2 Member 1 Yahrzeit Information: Member 2 Yahrzeit Information: Relationship of Deceased to Member 1 Relationship of Deceased to Member 2

5 Member 1 Yahrzeit Information: Member 2 Yahrzeit Information: Relationship of Deceased to Member 1 Relationship of Deceased to Member 2 Member 1 Yahrzeit Information: Member 2 Yahrzeit Information: Relationship of Deceased to Member 1 Relationship of Deceased to Member 2

6 Children s Individual Information Please complete the information below for each of your minor or college age children, listing them separately. Child 1 Information: Child 2 Information: Hebrew Hebrew English Birth Date (i.e. mm/dd/yyyy) English Birth Date (i.e. mm/dd/yyyy) Bar/Bat Mitzvah Date (if has occurred) Bar/Bat Mitzvah Date (if has occurred) Current Grade in School Current Grade in School Child 1 Child 2 Child 3 Information: Child 4 Information: Hebrew Hebrew English Birth Date (i.e. mm/dd/yyyy) English Birth Date (i.e. mm/dd/yyyy) Bar/Bat Mitzvah Date (if has occurred) Bar/Bat Mitzvah Date (if has occurred) Current Grade in School Current Grade in School Child 3 Child 4

7 Wish to Participate Form Please consider joining one of the following committees. All are critical to the functioning of the shul. If you have any questions as to the responsibilities involved with any of these committees, please contact Matthew Weitzman at or the shul office at or (858) Member 1: Bikur Cholim Finance Committee Guest Hospitality (i.e. meals and/or sleeping accommodations) Kiddush Marketing & PR Membership Committee Neighborhood Liaison Office Assistance Security Teams/Team Leaders Shul Ushering Social Events Committee Spring Fundraiser Committee Youth Program Development Member 2: Bikur Cholim Finance Committee Guest Hospitality (i.e. meals and/or sleeping accommodations) Kiddush Marketing & PR Membership Committee Neighborhood Liaison Office Assistance Security Teams/Team Leaders Shul Ushering Social Events Committee Spring Fundraiser Committee Youth Program Development

8 Biography and Photo Page Please tell us a little about yourselves and provide a photo, so that our members will recognize you and be able to welcome you to the community. Biography: Photo: Please attach a photo here that can be digitally scanned. The photo will be returned to you. If you have a digital photo already please it to

9 Dues Schedule July 1, 2008 June 30, 2009 Full Membership: If you join any time between the months of July December your dues contribution will be: Family $1, Single Student If you join any time after January 1 st, but prior to June 30 th your dues contribution will be: Family $ Single Associate Membership: We offer an Associate Membership. You MUST be a full paying member in good standing at another synagogue and provide proof of membership. Family $ Single

10 Membership Account Credit Card Authorization Please complete the following and return to the office (attention Annette Olson) either by mail: Congregation Adat Yeshurun 8625 La Jolla Scenic Dr. N, La Jolla 92037, or fax it to us at Name (Please Print) Date The membership year is from July 1 through June 30. Payment of dues must commence in July of each membership year, or the month in which you become a member, and your dues must be paid in full by June 30. I would like to make my dues payment over (please check the appropriate box). You must select one of the following options. 1 Payment 4 Consecutive monthly installments 8 Consecutive monthly installments I would like my operations expenses (other than dues) automatically charged to my credit card (please check the appropriate box). If you elect no, then expenses are due when incurred. Yes No I would like my Yom Kippur Pledge charged to my credit card (please check appropriate box) Yes, over how many months? No I hereby authorize Adat Yeshurun to debit my credit card for dues on the first day of each month for as long as I have outstanding operational dues. This authorization shall remain in effect each year until Adat Yeshurun receives written notification of cancellation. Credit Card Number Expiration Date Signature Name as appears on credit card Credit Card Type (please check the appropriate box): MasterCard Visa American Express

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